Director of the Center of Excellence of the Surgery of Obesity and Metabolic
Diseases. ... laparoscopic as well as bariatric surgery should attempt this
procedure.
CENTER OF EXCELLENCE FOR THE STUDY AND OBESITY TREATMENT
Laparoscopic One Anastomosis Gastric Bypass (LOAGB) vs. Standard Roux-en Y Gastric Bypass (RYGB) Retrospective Long-term Results in a series of LOAGB 2,200 patients vs. RYGB 477 patients
Miguel-A. Carbajo Caballero Director of the Center of Excellence of the Surgery of Obesity and Metabolic Diseases. Hospital Campo Grande, Valladolid, España
Minimising the Inter and Postoperative Risks of Gastric Bypass Stenosis
Stenosis Leak Bleeding
Leak Chronic Marginal Ulcer Bleeding
13-15 cm
Severe Dumping
8-10 cm
Regain or Faillored Weigth Loss
2-2.5 cm
Obstruction
Bilio – Pancreatic Limb: 250 – 350 cms Obstruction Internal Hernia Stenosis Leak Bleeding Volvulus
Possible Alkaline Reflux???
Two Anastomosis GB 12 Possible Risk Factors
One Anastomosis GB 4 Possibles Risk Factors
Laparoscopic Roux-en-Y gastric bypass: initial 2-year experience. Suter M, Giusti V, Heraief E, Zysset F, Calmes JM. Surg Endosc 2003;17: 603-9.
-Complication (20.5%) -Reoperation (8.4%): leak Internal Hernia subphrenic abscess Mortality
(4.6%) (2.8%) (0.9%) (0.9%)
CONCLUSIONS: It is a very complex operation. Long and steep learning curve (100150 pts). Weight loss and correction of comorbidities are similar to open surgery. However, only surgeons with extensive experience in advanced laparoscopic as well as bariatric surgery should attempt this procedure.
Laparoscopic management of complications following laparoscopic Roux-en-Y gastric bypass for morbid obesity. Papasavas PK, Caushaj PF, McCormick JT, Quinlin RF, Hayetian FD, Maurer J, Kelly JJ, Gagner DJ. Surg Endosc. 2003;17:610-4.
Complications (25.2%) Reinterventions (13.8%) Gastrojejunostomy stricture (8.9%) Intestinal Obstruction: (7.3%) adhesions (6), internal hernia in transverse mesocolon (3), jejuno jejunostomy stricture (3), cicatrix Roux limb at transverse mesocolon (3). Gastrointestinal bleeding (4%) Gastrojejunostomy leak (1.6%) Symptomatic gallstone disease (2.8%) Gastric remnant (0.8%) Negative laparoscopy to rule out anastomotic leak 3 deaths, 2 attributable to anastomotic leak.
Laparoscopic Roux-en-Y gastric bypass (LRYGB): 1500 Cases and 5 year Follow-up C. Boza, J. Salinas, A. Raddatz, … Obes. Surg. 2008;18 (8):975
Early Complications Intestinal Obstruction • Gastroyeyunal Stenosis •
Late Complications Intestinal Obstruction • Gastroyeyunal Stenosis •
(8.5%) (1.7%) (1.7%)
(12.3%) (2.8%) (4.6%)
4000 Case Series of Simplified Lap Gastric Bypass. Outcomes and Complications M. Galvao, A. Ramos, A. Carlo, … Obes. Surg. 2008;18 (8):916
Complications Marginal Ulcer • Gastroyeyunostomy Stenosis • Leakage • Digestive Bleeding •
Revisional Surgery Non satisfactory weigth loss • Complications • Silastic Ring Migration •
(11.3%) (1.2%) (4.6%) (0.9%) (0.5%)
(4.3%) (2.7%) (0.8%) (0.8%)
Small Bowel Obstruction After Antecolic Antegastric Laparoscopic Roux-en-Y Gastric Bypass Wihtout Division of Small Bowel Mesentery: A Single Centre, 7-Year Review M. Abasbassi, H. Pottel, B Deylgat Obes. Surg. (2011) 21: 1822-1827
“The
true rate of Internal Hernias may be underestimated in the literature. A summary recent literature regarding IH Antecolic Antegastric Roux-en Y Gastric Bypass shown a rate between 1.5% and 14.4%”
Causes of 30-day Bariatric Surgery Mortality: With Emphasis on Bypass Obstruction. E. E. Mason; K. E. Renquist; Y-H. Huang; M. Hamal; I. Samuel; Obes. Surg. 2008,17: 9-14
“In Bypass obstruction, the usual sequence of events begins with postoperative paralytic ileus... "Bypass obstruction" is the most urgent of all closed segment bowel obstructions... Contrast the earliest deaths at 2 days after bypass obstruction with the earliest death at 4 days following a leak”
Marginal Ulcer after Roux-en-Y Gastric Bypass B. Dillemans, S. Van Cauwengerg, J. Mulier Obes. Surg. 2009;19 (8): 958 In 54 (4,9%) of 1.104 patients, a marginal ulcer was diagnosed, an one 11% requiring surgical operation
Laparoscopic revision gastric bypass surgery for chronic marginal ulcers: a 10 year experiencie F. Tercero, Khan A., Nimen A., Brokne K., Higa K. Obes. Surg. 2008;19 (8): 958 38 laparoscopic revisions, 30 primary revisions and 42 therapeutic endoscopies were performed for intractable marginal ulcers from 1998 to 2008… It is associated with significant morbidity and high recurrence rate.
Laparoscopic Reoperative Bariatric Surgery: Experience from 27 consecutive patients. Michel Gagner et al. Obes. Surg., 2002; 12: 254-260
“ 10 to 25% of patients undergoing bariatric surgery will require a revision, either for unsatisfactory weight loss or for complications… In Gastric Bypass intervention, the revisional index varies between 3 to 15%.”
Reinterventions for Weigth Regain After RYGastric Bypass A. Guweidhi, F. Horber Obes. Surg. 2009;19 (8): 976
Following at 208 patients in the fouth year after lap-standard Roux-en-Y Gastric Bypass… showing a total of 39 (21%) of the reinterventions
Long-Term Results of Laparoscopic Roux-en- Y Gastric Bypass: Evaluation After 9 Years J.Himpens . Anneleen Verburgghe . Guy- Bernard Cadiere . Wouter Everaerts . Jan Willem Greve OBES SURG 2012; 22: 1586-1593
•
Percentage of excess BMI lost 56.2 ± 29.3% Patient satisfaction remained good in 76% of cases High rate and internal hernia 9.3%
•
Conclusions:
•
THE LRYGB ACCEPTABLE FOR EXCESS WEIGHT LOSS, OF HIGHER RATE OF INTERNAL HERNIAS
• •
•
NOT ACHIEVE FULL MONITORING TO ALL PATIENTS
Laparoscopic Roux-en-Y gastric bypass: 10-year follow-up K. Higa, T. Ho, F. Tercero, T. Yunus, K. Boone SOARD, 2011; 7: 516-525
*Mean excess weight loss (EWL) was 57% at 10 years *33.2% failed to achieve an EWL of >50% *35% of the patients had ≥ 1 complication during follow-up - Internal Hernia rate was 16% - Gastro-yeyunal stenosis rate was 4.9% - Marginal ulcer rate was 4.5% *Only 18% remained nutritionally intact during follow-up CONCLUSION: ”ALTHOUGHT OUR GOAL HAS BEEN TO IMPROVE THE HEALTH AND QUALITY OF LIFE OF OUR PATIENTS, MEASUREMENTS OF SUCCESS REMAIN NEBULOUS”
Roux en Y Gastric Bypass: Our experience in 477 Patients With 11-Year Follup-up TECHNIQUES
•
OPEN RETROCOLIC RETROGASTRIC ROUX –EN-Y (Mc LEAN):……92 OPEN RETROCOLIC DISTAL ROUX –EN-Y (SALMON)………………..26 OPEN RETROCOLIC ANTEGASTRIC ROUX –EN-Y (CAPELLA):……103 HAND MADE ASISTED LAPAROSCOPIC OR (CAPELLA):……………………………………………………………………182 TOTALLY ANTEGASTRIC ANTECOLIC LAPAROSCOPIC:……………74
•
TOTAL:…………………………………………………………………………477
• • • •
FOLLOW-UP •
ONLY 86 PATIENTS (18%) WAS POSSIBLE ACHIEVE FULL MONITORING TEN-YEARS FOLLOW-UP
Roux en Y Gastric Bypass: Our Experience in 477 Patients With 11-Year Follow-up (1994-2002)
Early Major Complications and Mortality Perioperative
Nº
%
Intra-abdominal bleeding
4
0.8%
Gastro-intestinal bleeding
3
0.6%
Intrabdominal abscess
4
0.8%
Gastric pouch fistula
2
0.4%
Gastric remmanent leak
1
0.2%
Gastro-jejunal leak
10
2%
Small bowell oclusion
3
0.6%
Internal hernia with obstruction
12
2.5%
Malrotación at Roux en Y level+obstruccion
2
0.4%
Mortality (bronquial breaking)
1
0.2%
SUBTOTAL
42
8.8%
Roux en Y Gastric Bypass: Our experience in 477 Patients With 11-Year Follup-up (1994-2002)
Late Major Complications Middle and Long term
Nº
%
Internal Hernia
6
1.2%
Gastro-jejunal stenosis
6
2.9%
Severe Marginal ulcer
12
2.5%
Gastro-gastric comunication (chronic ulcer)
3
0.6%
Gastric pouch cancer
1
0.2%
Severe Dumping syndrom
14
2.9%
Neuropaty (Vit B1 deficit)
2
0.4%
Malnutrition
4
0.8%
62
13%
110
24.5%
Weight Regain SUBTOTAL
Laparoscopic Roux-en-Y vs. Mini-Gastric bypass for the treatment of morbid obesity: a prospective randomized controlled clinical trial. Lee WJ, Yu PJ, Wang W, Chen TC, Wei PL, Huang MT. Ann Surg 2005;242:20-8.
METHODS Eighty patients randomized LRYGBP (n= 40) or LMGBP (n= 40); followed 2 years. Late complication, EWL, BMI, GIQLI, and comorbidities.
RESULTS - One conversion (2.5%) in LRYGBP group - Operation time in LMGBP group (205 vs 148, p< 0.05) - Operative morbidity LRYGBP group (20% vs 7.5%, p< 0.05) -Residual excess weight
